How to manage a pregnant patient at 36.5 weeks gestation with new-onset proteinuria and symptoms concerning for preeclampsia?

Management of Severe Preeclampsia at 36.5 Weeks Gestation

This patient requires immediate delivery after maternal stabilization with magnesium sulfate for seizure prophylaxis, given the gestational age of 36.5 weeks, severe proteinuria (protein/creatinine ratio 10.4), rapidly worsening proteinuria (24-hour urine doubled in 8 days), and concerning symptoms including headache and significant edema. 1, 2, 3

Immediate Actions Required

Confirm Severe Preeclampsia Diagnosis

• This patient meets diagnostic criteria with blood pressure measurements (currently normal but requires continuous monitoring), severe proteinuria (protein/creatinine ratio 10.4, far exceeding the diagnostic threshold of ≥0.3), and concerning symptoms including headache and generalized edema 1, 3
• The rapidly escalating proteinuria (24-hour urine increased from 3880 mg to 7774 mg over 8 days) indicates disease progression and warrants urgent intervention 2, 3
• Hemoglobin of 10.1 g/dL with platelets at 161,000/μL requires close monitoring for HELLP syndrome development, though current platelet count is above the critical threshold of 100,000/μL 2, 4

Initiate Magnesium Sulfate Immediately

• Administer magnesium sulfate for seizure prophylaxis immediately, given the presence of severe proteinuria and headache, which are neurological warning signs 1, 2, 3
• Loading dose: 4-5 grams IV over 5 minutes, followed by maintenance infusion of 1-2 grams/hour 2
• Monitor deep tendon reflexes before each dose, respiratory rate continuously (magnesium toxicity causes respiratory depression), and urine output hourly via Foley catheter with target ≥100 mL/4 hours 2

Blood Pressure Management Strategy

• Although current blood pressure is normal, establish continuous or every-4-hour monitoring while awake, as severe hypertension can develop rapidly 1, 3
• If blood pressure reaches ≥160/110 mmHg persisting for more than 15 minutes, initiate urgent IV antihypertensive therapy within 15 minutes 1, 2
• First-line agent: IV labetalol (20 mg IV bolus, then 40 mg after 10 minutes, followed by 80 mg every 10 minutes to maximum 220 mg) or oral nifedipine 5, 1, 2
• Target blood pressure: systolic 110-140 mmHg and diastolic 85 mmHg to prevent maternal cerebral hemorrhage while maintaining uteroplacental perfusion 1, 2, 3
• Avoid ACE inhibitors, ARBs, and direct renin inhibitors due to severe fetotoxicity causing renal dysgenesis 1
• Avoid diuretics as they further reduce plasma volume, which is already compromised in preeclampsia and worsens uteroplacental perfusion 1, 3

Comprehensive Laboratory Assessment

Immediate Laboratory Monitoring

• Obtain complete blood count with focus on hemoglobin (current 10.1 g/dL suggests possible hemolysis) and platelet count (current 161,000/μL, monitor for progressive thrombocytopenia) 1, 2, 3
• Comprehensive metabolic panel including liver enzymes (current AST 36, ALT 7 are reassuring but require serial monitoring), creatinine (current 262 mg/dL in urine is concerning), and uric acid 1, 2, 3
• Peripheral blood smear to assess for hemolysis, as the combination of elevated alkaline phosphatase (377) and lower hemoglobin raises concern for HELLP syndrome 2
• Repeat laboratory tests at least twice weekly or more frequently given the rapid clinical deterioration evidenced by doubling proteinuria 1, 2

Critical HELLP Syndrome Surveillance

• The combination of hemoglobin 10.1 g/dL, alkaline phosphatase 377, and headache warrants urgent evaluation for HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) 2, 4
• Epigastric or right upper quadrant pain would be a hallmark symptom suggesting hepatic capsule distension and mandates immediate delivery 2, 4
• Progressive thrombocytopenia or progressively abnormal liver function tests are absolute indications for immediate delivery 2

Fetal Assessment Protocol

Immediate Fetal Surveillance

• Perform ultrasound assessment for fetal biometry, amniotic fluid volume, and umbilical artery Doppler to evaluate for intrauterine growth restriction 1, 3
• Initiate continuous electronic fetal heart rate monitoring to assess fetal well-being 1, 3
• Non-reassuring fetal status is an absolute indication for immediate delivery regardless of other factors 2, 3

Delivery Planning

Immediate Delivery Indicated

• At 36.5 weeks gestation with severe preeclampsia (evidenced by severe proteinuria, rapidly worsening disease, and neurological symptoms), delivery should proceed immediately after maternal stabilization with magnesium sulfate 1, 2, 3
• The American College of Obstetricians and Gynecologists recommends immediate delivery for all women with preeclampsia at ≥37 weeks gestation, and this patient at 36.5 weeks with severe features and rapidly progressive disease meets criteria for expedited delivery 2, 3
• Induction of labor is preferred over cesarean delivery unless obstetric indications for cesarean exist, as vaginal delivery is associated with improved maternal outcomes 2, 3

Absolute Indications for Immediate Delivery Present

• Severe persistent headache in the setting of severe proteinuria constitutes a neurological warning sign requiring immediate delivery 2, 3
• Rapidly progressive proteinuria (doubling in 8 days) indicates accelerating disease that will not stabilize with expectant management 2
• Any development of the following would mandate immediate delivery: repeated episodes of severe hypertension despite treatment, progressive thrombocytopenia, progressively abnormal liver or renal function tests, pulmonary edema, severe intractable headache, repeated visual scotomata, eclamptic seizures, or non-reassuring fetal status 1, 2

Critical Monitoring During Stabilization

Maternal Monitoring Requirements

• Continuous or every-4-hour blood pressure monitoring 1, 3
• Hourly urine output via Foley catheter with target ≥100 mL/4 hours (or >35 mL/hour) 2
• Pulse oximetry monitoring with maternal early warning if <95% 2
• Deep tendon reflexes and clonus evaluation to monitor for magnesium toxicity and disease progression 1, 3
• Assess for maternal agitation, confusion, unresponsiveness, non-remitting headache, visual disturbances, and shortness of breath 2

Critical Pitfalls to Avoid

Common Management Errors

• Do not use blood pressure level alone to determine disease severity—this patient has normal blood pressure but severe disease based on proteinuria and symptoms 1, 3
• Do not delay delivery based on serum uric acid level or degree of proteinuria as indications for timing—these are not reliable markers for delivery decisions 2, 3
• Do not administer NSAIDs for analgesia if delivery occurs, as they worsen renal function in preeclampsia 1
• Do not attempt expectant management at this gestational age with severe features—all cases of preeclampsia can rapidly progress to emergencies 2, 3
• Do not use low molecular weight heparin for prevention, as it is not indicated even with prior early-onset preeclampsia 1

Medication Contraindications

• Absolutely contraindicated: ACE inhibitors, ARBs, direct renin inhibitors (severe fetotoxicity), and diuretics (worsen plasma volume depletion) 5, 1
• Avoid short-acting oral nifedipine, especially when combined with magnesium sulfate, due to risk of uncontrolled hypotension and fetal compromise 2
• Intravenous hydralazine should no longer be considered first-line as it is associated with more perinatal adverse effects than other agents 5

Hospital Setting Requirements

• Management must occur in a hospital with appropriate obstetrical care facilities, maternal intensive care capabilities, and coordination with maternal-fetal medicine specialists, neonatology, and anesthesiology teams 1
• Neuraxial analgesia and anesthesia are strongly preferred as first-line anesthetic techniques in the absence of thrombocytopenia 4
• Magnesium sulfate must continue during labor and for at least 24 hours postpartum to prevent seizures 2, 6